The MAHAY Pilot: Tackling stunting and promoting child development through integrated interventions in Madagascar EMANUELA GALASSO (DECRG) JUMANA QAMRUDDIN (HAFH2) * JOINT WITH LIA FERNALD (UC BERKELEY), CHRISTINE STEWART (UC DAVIS), ANN WEBER (U RENO), LISY RATSIFANDRIHMANANA (U ANTANANARIVO)
Acknowledgements: A collaborative effort • PNNC/ONN Team • World Bank operational team: Jumana Qamruddin, Voahirana Rajoela, Valerie Ranaivo, Lisa Saldanha • Local collaborators: • Early stimulation component (Lucie Razanatsimoiva, Elisa Rakontondrainibe, Noa Razanajatovo) • Intensive counseling team (Raphael Rakotozandrindrainy, Alban Ramandrisoa) • Proessecal survey firm • Biomarker data collection (Institute Pasteur, Madagascar) • International collaborators: • Harold Alderman (IFPRI), Charles Arnold (UC Davis), Esther Chung (UNC), Maria Dieci (UC Berkeley) • Jamaica home visiting team (Christine Powell, University West Indies) • LNS- Nutriset • ASQ-I (Jantina Clifford & Kimberly Murphy, University of Oregon) • Biomarker analysis (Juergen G. Erhardt, ELISA method) • Funding Strategic Impact Evaluation Fund (SIEF), Early Learning Partnership Program (ELP), World Bank Innovation Grant, World Bank Research Committee, Japan Nutrition Trust Fund, Power of Nutrition Trust Fund. implementation: Government of Madagascar
Outline • 1. Context and Background • 2. Madagascar’s National Community Nutrition Program (PNNC) • 3. The Mahay Pilot: Rationale and Design • 4. The Mahay Pilot: Results • 5. The Mahay Pilot: Conclusions • 6. Informing Policy
1. Context and Background
(i) The narrow(er) window of opportunity in Madagascar Height for age z-score • ~50% children under 5 y (control group) moderately or severely -1 stunted • Stunting starts during -1.5 pregnancy: 25% of the z-score children are born stunted -2 • On average children are stunted by 12m of age (as -2.5 opposed to 24m). 0 6 12 18 24 30 36 age in months Source: Etude Mahay, control group
Early nutritional status (0-3y) associated with better skills during school age (7-10y) Sustained Attention (z-score) Vocabulary (z-score) 0.5 .5 .5 0.5 sust atten age-adjusted z-score 0 0 0 0 -0.5 -.5 -0.5 -.5 -1.0 -1 Height-for age Height-for age height-for-age height-for-age ---- Weight-for-age ---- Weight-for-age -1.5 -1.0 -1.5 -1 weight-for-age weight-for-age -5 -4 -3 -2 -1 0 1 2 -5 -4 -3 -2 -1 0 1 2 -4 -2 0 2 -4 -2 0 2 '04 anthropometric z-score Lowess with running mean smoothing - bandwidth 0.6 Anthropometric z-score Own calculations: Enquete Anthropometrique et de Developpment des Enfants 2004-2011
Equity: investing early can prevent learning gap Sustained attention z score: wealth gradient by age Vocabulary z score: wealth gradient by age 1.5 1 1 .5 .5 0 0 -.5 -.5 -1 -1 3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10 ageyears ageyears Q1 Q2 Q1 Q2 Q3 Q4 Q3 Q4 Q5 Q5 • Large socio-economic gradients in childhood development emerge early even in low income environments • Widen with age before school and map into sizeable learning gaps • 20% gaps mediated by home environment Galasso, Weber and Fernald (2019) “Dynamics of child development: Analysis of a longitudinal cohort in a very low income country” WBER, 33(1), 140-159.
2. Madagascar’s Community-Based Nutrition Program
An existing at scale service delivery platform • Long standing program, starting in 1999 o Focused on growth monitoring/promotion and nutrition education o Surveillance acute malnutrition + referral to health centers o 1 Locally elected Community Health Worker o Communities with ~ 100 children 0-2 years old o Broad coverage across the country, scaled-up since mid 1990s
A long term evaluation of the program (1997-2011) 1 st phase 2nd phase 1997/98 2004 2011 1/3 never sites 1/3 late sites 1/3 early Very small number of sites closed sites Weber, A.M., Galasso, E. Fernald, L.C.H.. 2019. Perils of scaling up: Effects of expanding a nutrition programme in Madagascar. Maternal and Child Health.15,S1
The challenges of scaling-up 0.5 2004 2011 Early 2011 Late 0.4 0.3 0.2 SD 0.1 0 Weight-for-age Height-for-age Weight-for-height -0.1 • Employed Difference in Difference methodology with staggered adoption • Benefits on nutritional outcomes (WAZ) among early adopters, sustained over time
Why? Loss of focus on quality • Rapid expansion to new sites without attention to quality of training • Increased population pressure brings about larger workloads for the nutrition workers • Inclusion of children 3-5 drain on nutrition worker resources
3. The Mahay Pilot: Rationale and Design
Our starting point: Madagascar’s ongoing nutrition program Pre-primary 3-6 focus on survival Health Nutrition o Insufficient coverage o Gaps in services o Quality issues o Separate sectors with referrals o Emergency program post-crisis Pre-schools Facility based Community based health nutrition
We embedded Mahay into the existing at scale service delivery platform • Back to the drawing board to tackle stunting and promote early child development: Target pregnancy and infancy – first 1000 days Use the existing program (PNNC) as a counterfactual (T0) Feasible policy space post crisis? Integration with nutrition-sensitive interventions not feasible Test new ‘add-ons’ in a cluster RCT: Expand the quality/intensity and scope of the existing program: test value added and mechanisms Assess cost effectiveness for scale up Fernald, Galasso, Qamruddin, Ranaivoson, Ratsifandrihamanana, Stewart, Weber (2016) “A cluster-randomized, controlled trial of nutritional supplementation and promotion of responsive parenting in Madagascar: the MAHAY study design and rationale” BMC Public Health ; 16:466
Mahay Study: intensifying quality and scope Added community worker for home visits • Global Early Intensive Counseling to • Bangladesh evidence/local stimulation to exchange address barriers to change expertise adaptation with improve of Reach Up Jamaica BRAC/A&T development Lipid-based nutrient • supplementation UCDavis/Gates studies, with • Pregnant & lactating women potential local • Children during weaning production
Mahay Study Design: a clustered RCT T0 T1 T2 T3 T4 Child stimulation, home visits 2x/mo LNS for P&L women: 40 g, 235 kcal LNS for children 6-18m: 20 g, 118 kcal Intensive counseling, added nutrition worker, home visits, enhanced training on problem solving / addressing barriers, Existing U-PNNC program with a focus on first 1000 days in group counseling sessions, growth monitoring, and cooking demonstrations
Mahay research questions How does each strategy affect linear growth faltering and child development? (T1-T4 vs T0) Does the timing/duration of supplementation make a difference? (T2 vs T3) What is the value added of integration? T2,T3 vs T1: does counseling alone affect behaviors and child outcomes? Direct effect supplementation/ behavior T4 vs T1: does counseling on early stimulation enhance the impact of nutrition counseling on child outcomes? Cost effectiveness
T1: intensive counseling in home visits Added social worker (CHW) to reinforce behavioral change through home visits (as in BRAC-Alive&Thrive Bangladesh) Preventative home visits starting once during pregnancy, with decreasing frequency (monthly 0-8, bimonthly 9-12, quarterly 12-24) as opposed to curative (home visits after growth faltering) enhanced training with emphasis on listening skills, problem solving and addressing barriers (food diversity, animal source food, prenatal/postnatal visits, basic food security)
T2: T1 + lipid based supplementation to children 6-18m preventive lipid based supplement (not curative as in PlumpyNut) In-kind transfer with comprehensive nutrient content: micro- (iron, zinc, essential fatty acids, vitamin A, folic acid, vitamin C) AND macro- nutrients (fats, proteins, carbohydrates) 2 daily sachets 10g Cost ~ 3.65$/child/month (~ 10,900 MGA) 118 kcal, ~100 % of the recommended nutrient intakes (RNI), 9.9g fats, 2.6g proteins Cost benchmark: CCT transfer in Madagascar (15,000 MGA UCT, + 5,000/child 6-12yo)
T3: T2 with supplementation to pregnant/lactating women Supplement during pregnancy and lactation (-6,6) in addition to children 6,18m: 40g/day, 235 kcal, 1-2 x recommended dietary allowance (RDA) of micronutrients for pregnant women, 19.7g fat and 5.2g proteins Cost ~7.30$/woman/month (~ 22,000 MGA)
T4: integrated nutrition and early stimulation local adaption protocol from the Reach Up and Learn Jamaica high investment in training and coaching bi-monthly home visits 6-30 months of age in addition to the nutrition counseling
Randomization and sample selection • 125 Clusters • Stratified, 5 regions • 25 clusters per arm • T1-T3 delivered to all eligible households, T4 to study sample • Total sample at baseline n=3750 • Stratified sampling, 3 age cohorts • 10 households per age cohort per cluster • Replaced if moved permanently out of catchment area. (not if died)
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